Diabetic retinopathy is the leading cause of blindness in working-age adults, and both the disease and ensuing blindness disproportionately affect American Indians and Alaskan Natives (AI/AN). The Agency for Healthcare Research and Quality reported that annual diabetic eye exams would save the government an estimated $472 million dollars per year. The cornerstone of prevention of vision loss is annual eye exams and early treatment, but less than 50% of AI/AN diabetic patients receive annual eye exams. Among northwest AI/AN, only two of the 43 federally recognized tribes have affiliated clinicians who can provide yearly eye exams, and the long distance of many rural reservations from urban eye care centers complicates routine care for diabetic retinopathy. This proposal will address three critical gaps in knowledge: 1) the efficacy for detecting diabetic retinopathy with telemedicine and traditional surveillance methods;2) the health behavior factors related to receiving annual diabetic eye examinations with telemedicine and traditional surveillance methods;and 3) the cost-effectiveness of telemedicine and traditional surveillance methods. The impact of this project will be large if we can achieve even a small increase in the proportion of patients receiving eye exams. This benefit increases further if we show an increase in cost-effectiveness and sensitivity to detecting diabetic retinopathy. Future experiences and data from this project will provide the framework for changes in the national and statewide guidelines in the delivery of diabetic eye exams as well as a larger randomized clinical trial. Our research group's expertise, track record, and established relationships make us uniquely positioned to address these gaps in knowledge to prevent blindness from diabetic retinopathy.